Part 1: BUSINESS INFORMATION

The Business DBA Name:

Corporation Name:

Federal ID:

Entity Type:
corp

LLC

Sole Prop

Partnership

Type of Business:

Business Address:

City:

State:

ZIP Code:

State of Incorporation:

Work Phone:

Cell Phone:

Fax:

Email:

Business Website:

Product Sold:

Years in Business:

Start Date of Business:

Business Property:
RentOwn

Monthly Rent or MTG Payment ($):

Term on Lease:

Do you have a cash advance now?
YesNo

With whom? (If yes):

Balance?:

Part 2: OWNER INFORMATION

Owner Full Name:

% of Ownership:

S.S. #:

Driver's License #:

D.O.B.:

Personal Credit Score:

Home Address:

City:

State:

ZIP Code:

Home Phone:

Personal Email:

Personal Property:
Rent
Own

Years at Current Address:

Part 3: CO-OWNER INFORMATION

Co-Owner Full Name:

% of Ownership:

S.S. #:

Driver's License #:

D.O.B.:

Personal Credit Score:

Home Address:

City:

State:

ZIP Code:

Home Phone:

Personal Email:

Personal Property:
Rent
Own

Years at Current Address:

AUTHORIZATION

By signing below, each of the above listed business and business owner/officer (individually and collectively, "you") authorize [Your Company Name] and each of its representatives, successors, assigns and designees ("Recipients") that may be involved with or acquire commercial loans having daily repayment features or purchase of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, "Transactions") to obtain consumer or personal, business and investigative reports and other information about you, including, without limitation, credit card processor statements and tax returns, from one or more consumer reporting agencies, such as TransUnion, Experian, and Equifax, and from other credit bureaus, banks, creditors and other third parties. You also authorize [Your Company Name] to transmit this application form, along with any of the foregoing information obtained in connection with this application, to any or all of the Recipients. You acknowledge that the Recipients may rely on this authorization in order to proceed with the Transactions. You also authorize [Your Company Name] to contact you via email, text, or phone regarding this application or the Transactions.

Signature:

Date: